(In
following, aredescribed
only auscultatory percussion reflexes, signs, manoeuvres and tests,
which are routinely assessed, in order to perform Biophysical Semeiotics.
Other interesting reflexes, specific and useful in ascertaining both
physiological and pathological particular conditions, are exhaustively
illustrated in previous articles: See Bibliography).

Manoeuvres.

1)
Erythropoietin
Evaluation (Baserga's Sign): with the subject to be examined as usually psichophysically
relaxed and in supine position, doctor assesses for the first time the
RESHS (See later on); soon thereafter, doctormust stimulate trigger-points of the the skin at the level of VII
– VIII thoracic dermatomeres (i.e., right and/or left quadrants of
abdominal surface), by pinching with mean intensity for about15 sec. Kidneys size increases, due to renal congestion and, then,
appears their decongestion, which stimulates also Erythropoietin
secretion.

After
3-5 sec. interruption of such stimulation, RESHS has to be evaluated for
the second time: in healthy, latency time of gastric aspecific reflex
– during persistent digital pressure on mean line of sternal body and
iliac crests (spleen trigger-points are not useful) lowers from
basal value 10 sec. to 6 sec., due to bone marrow stimulation by
Erythropoietin (E.) under physiological condition. Interestingly, in
case of iron deficiency syndrome, with or without anemia, E.
receptors of the bone marrow become less ornotsensitive at all
to the this substance,so
that lt. persists identical (= 10 sec.) in a second evaluation,
analogously in case of lowered E. secretion, because of kidneys
insufficiency, (for instance, hydronephrosis secondary to high
lithiasic obstruction syndrome).

Of
interest, analogouslyE.
evaluation can be performed by means of “intense” digital pressure,
lasting 10 sec., applied on cutaneous projection area of the heart, and
with identical procedure, described above. In case of ischaemic heart
disorder, or in case of other cardiac disease, lt. of RESHS does not
lower, at all, due to the basalexcessive
secretionof E., NO free
radical andnatriuretic
peptide type A, from the diseased heart, which brings about receptors
down-regulation in both bone marrow and kidneys (See later on : Nad
assessement).

3)
Restano’s
Manoeuvre. It is composed of the simultaneous application of boxer’s
test plusapnea test (See
later on), i.e. a dynamic sensitized test, since it induces sympahetic
hypertone. Restano’s Manoeuvre is very useful, for instance, in
evaluating RESHS in case of numerous diseases, when basal value (lt. =
10 sec. intensity 1 cm.) seems to be normal, but after the
manoeuvre becomes clearly pathological : lt lowers to 3 sec., with
intensity > 1 cm. and enhancing lt. of 8 sec.or less (Restano’s
Manoeuvre type B); in type A intensity is £
1 cm. and enanhing lt. 9 sec.

In healthy, all parameters are unchanged: sometimes intensity of reflex is
< 1,5.

There
is, morevoer, the so-called modified Restano’s manoeuvre: subject to
be examined clenching only one
fist, so that is possible utilizing the pulp of a finger of the other
hand, by performancing digital microvascularunit diagram, useful in
identifying oncological terrain. (See later on).

4)
Valsalva’s
Manoeuvre. Notoriously, this manouvreprovokes increasing of acetyl-choline, unavoidable, for instance,
in the biophysical evaluation of endothelial function evaluation.
This manoeuvre isso well
known, that I leaves out to describe it.

Reflexes.

1)
Caecum
reflex. Stimulatinga large number of trigger-points of all biological systems, after
a variable latency time (lt), in healthy fixed in well defined tissue,
brings about caecum dilation: physiologically, the reflex lasts £
4 sec., and then the viscera volume returns to basal size for >3
<4 sec., i. e.for the sametime
as the fractal dimension, calculated in a more sophysticated and
refined manner.

6)Cerebral-gastric
aspecific reflex. Digital pressure (type I) and/or nail pressure (type
II = pathological) bring about gastric aspecific reflex. In
healthy, lt. of type I reflex is 6 sec., while type II reflex, absent
under physiological condition, araise in case of epileptic focus,
even silent, i.e. in asymptomatic patients, as well as in other cerebral
pathologies, as meningitis, tumour, a.s.o., in association with type I ,
which reveals a lt < 6 sec.

7)
Cerebral-caecum
reflex. Cerebral trigger-points stimulation provokes caecum dilation;
these parameters, however,appear
to be the same as those of cerebral-gastric aspecific reflex. Obviously,
it can be utilized particularly in patient, who underwent complete gastrectomy.

8)
Cerebral-ureteral
reflex. Digital pressure of low-mean jntensity, on cerebral
trigger-points, provokes three ureteral reflexes, upper, middle a lower
ureteral reflex. They are unavoidablealso to evaluatingcerebral
vasomotility and vasomotion, even in well localized area.

17)Descending
colon-gastric aspecific reflex. Under the same condition, described
above, appears the gastric aspecific reflex.

18)Esophageal
Reflex.A large number of
reflexes, starting from nervous receptors localized in almost all
biological systems, end in esophageal wall, causing its dilation and LES
contraction, lasting for diverse time, organ-depending, in both
physiological and pathological conditions.

19)
Gastric
aspecific reflex. In daily practice represents the most frequent reflex
to be ascertained, under both physiological and pathological situations,
due to the fact that in the stomach, notoriously, bring to an end
numerous reflexes, originating from everywhere in human body.
“Vagale” gastric aspecific reflex : fundus and body of stomach are
dilated, whereas antral-pyloric region contracts. Less frequent is
“sympathetic” gastric aspecific reflex, in whichthe stomach dilates completely.

22)Liver-ureteral
reflexes.Light
digital pressure on liver projection area brings about three ureteral
reflexes, useful in evaluating vasomotility and vasomotion.

23)Oculo-gastric
aspecific, -esophageal, caecunand
–ureteral reflex. Analogously, light-mean digital pressure on
an eye-ball (when eye is closed, of course) causes the known reflexes
after a latency time different, in relation to local condition.

24)Pancreatic-caecum,
-gastic aspecific, -ureteral and –esophageal reflex. Prolonged
pinching at level of VI thoracic dermatomere (skin of right or left
hypochondrium, i.e. the skin covering costal arch,right or left, along middle-parasternal-line) causes the well
known reflexes.

25)Splenic
reflex. Stimulating numerous trigger-points provokes splenic reflex,
i.e. thesize of spleen
increases for about 6 sec. due to it congestion, and thereafter it comes
back to normal, basal value.

26)Splenic
gastric aspecific, -caecum, -ureteral reflex. Digital pressure of mean
intensity, applied on cutaneous projection area of spleen causes the
well known reflexes.

27)
Ureteral
reflex. Ureteral reflex (es) is (are) provoked by the stimulation of
numerous trigger-points of all tissues; there are three important
ureteral reflexes, which really play a primary role in evaluating vasomotility
and vasomotion of all biological systems, because their fluctuations
parallel those of arterioles (= upper ureter), interstitum (ureter
“in toto”) and, respectively, nutritional capillaries andvenules (= lower ureter). These ureteral reflexes enabledme to investigate clinically tissue-microvessel-units of every
biological systems, allowing thus the foundation of the Clinical
Microangiology.

Signs.

1)Bella’s
sign, classic and variant. In case of retrocaecal appendicitis,
until now really difficult to recognize clinically (but not only
at the bed-side) with the aid of old, accademic, physical semeiotics,
the patient bends its stretced right leg towards abdomen: the
“spontaneous” GTC rapidly appears (100% of cases), after a
gastric aspecific reflex of only 1-2 sec.lt and lasting3 sec.: Bella’s Sign “classic” (Bella’s Sign “variant”:
patient bends the left leg in identical manner, as described
earlier, with the same results in case of appendix located in left
ileo-pelvic region). Inhealthy,
under identical above-described conditions, lt of gastric aspecific
reflex is 10 sec., duration > 5 sec. and GTC intensity is < 2 cm.Interestingly, the degree of reflexes paramaters results the same
in next signs, pointing out internal and external coherence of
biophysical semeiotic theory.

Analogously,
but most desirably, doctor applies digital pressure on precise cutaneous
projection area of the inflammed appendix, previously localized
by means of auscultatory percussion: rapidly arise the same reflexes
above-illustrated, with identical parameters, including GTC.

3)Curri’s
sign. In patients, former involved by myocardial infarct, upper
ureteral reflex is spontaneously present, and fluctuates in
chaotic-deterministic manner, although with low fractal dimension.

4)Daneri’
sign. In healthy, minimal vertical diameter of broncho-vascular-hilar
system in both lungs appears to be < 2 cm..

In
case of polmonary disease as well as during BALT activation this
value increases, in relation to the severity of underlying disorder.

Of
interest, identical biophysical semeiotic signs are brought about, in
a characteristic manner, by persistent pinching of dorsal (back)
site of a hand in case of connective tissue diseases.

2)Cystic
syndrome. In presence of cyst in whatever organ as well as of dilation
of an artery, e.g., or viscera,as
ureter, digital pressure stimulates local trigger-points, carrying out
esophageal, gastric aspecific, and ureteral “in toto” reflex (=
ureter dilates in every part).

3)
Congenital Acidosic Enzyme-Metabolic Histangiopaty Syndrome (CAEMH).
This syndrome points out a mitochondrial, inherited, functionalcytopathology: digital pressure on cutaneous projection area of right
cerebral hemisphere provokes the gastric aspecific reflex, which appears
more intense than that brought about by identical stimulation applied on
left cutaneous area of homolateral cerebral hemisphere,
indicating the prevalence of right Planum temporale.

4)Reticulo-Endothelial System Hyperfunction Syndrome(RESHS).This very
useful syndrome corresponds to both erythrocyte sedimentation rate (ESR)
and proteins electrophoresis, but is more sensitive and specific. This
syndrom has to be ascretained most oftenin daily pracice. In healthy, digital pressure of mean intensity,
applied on medial sternal-body line, iliac crests and cutaneous
projection of spleen, after 10 sec. exactly, provokes gastric aspecific
reflex (besides caecum dilation and spleen decongestion).

In
practice, it is enough to assess exclusively gastric aspecific reflex.
There are three types of RESHS: RESHS “complete”, when sternal-body,
iliac crests and spleen are trigger-points for the syndrome. The lt
appears to be 6 sec. or less, in case of infective diseases, caused by Gram-positive
bacilli, viruses ofcommon
infancy diseases, rheumopathies and malignancy. An other type
is RESHS “intermediate”: spleen is trigger-point of the syndrome,
but gastric aspecific reflex is clearly less intense during spleen
stimulation, pointing out infection caused by Gram-negative agents.
Finally, RESHS incomplete indicates characteristically the presence of
flu viruses: the spleen stimulated does not provoke any reflex.

Tests.

1)Apnea
Test : the subject to be evaluated is invited to not breath, bringing
about sympathetic hypertone.

2)Boxer’s
Test: closing intensively both hands (fists) an individual provokes sympathetic
hypertone. We have to remember, at this point, Restano’s
manoeuvre, i.e. simultaneous application of both tests: apnea and
boxer’s test.

9)Simulated
Urination Test: an individual is invited to press its abdomen as to
urinate. In healthy, appears suddenly ureteral reflex “in toto” as
well as gastric aspecific reflex, which last only for 3-4 sec. and then
rapidly disappears.On the
contrary, in case of urinary tract disorder, non neoplastic in origin,
including Benign Prostatic Hypertrophy, both reflexes persist for longer
time.Interestingly, in
case of malignancy of urinary tract, after 3-5 sec. gastric
aspecific reflex is rapidly followed by the characteristic Gastric Tonic
Contraction. In case of renal cyst, apart from its size and
degree, the test causes cystic syndrome: in practice, ureter dilates
“in toto”.

Finally,
in presence of renal-lithiasis, even clinally silent, arises the
typical “litiasic” reflex : both stomach and uretere dilate
intensively, but soon thereafter followes its reduction of 1/3 of
intensity.

Particular
Evaluations.

1)Cholesterol
and Triglycerid (tissue) Evaluation. Digital (hand) pressure of mean
intensity, applied on cutaneous prjection of the liver, physiologically
provokes gastric aspecific reflex after lt. of³7 sec.with a
duration< 4 sec.and intensity £
2 cm. Thereafter, the reflex diseappears completely for > 3
sec. < 4 sec.(differential latency time, which notoriously
parallels to fractal dimension: 3,81). When lipids synthesis is
pathologically increased, the liver-gastric aspecific reflex presents a
typical behaviour: lt. < 7 sec., intensity > 2 cm. e duration >
4 sec.Interestingly, the
reflexdoes not entirely
disapear, residuing a small gastric aspecific reflex, the intensity
of which is directly related to that of lipids synthesis. Of particular
interest is the sensibilized evaluation by mean of Ferrero-Marigo’s
Manoeuvre (See earlier): apart from present lipids concentration,
the persistinggastric
aspecific reflex – the residuing one -appears to be > 2cm., although its basal value is in normal
ranges, as in patient with earlier hyperlipidemia but normal at the
moment.

2)Hyperinsulinemia-Insulinresistance
Test.By means ofrenogram as well as surrenogram,the assessement of this dangerous and insidious situation,because almost always asymptomatic, can be easily performed. As a
matter of facts, in healthy, acute insulin secretion peak provokes
augmentation of kidney size of 3 cm., after lt. of about 10 sec.; kidney
fluctuations (Phase C in diagrams) last for 8 sec.(NN = 6 sec.). On the contrary, due to receptorsdown regulation, kidney size increasing is smaller
or completely absent, in correlation with the seriousness of
hyperinsulinaemia-insulinresistance. Under identical condition, surrenogram
provides to doctor the same information: in healthy, the first
oscillations persist in normal intensity ranges, but in case of
hyperinsulinaemia-insulinresistance, starting from the third normal
fluctuation , one observes fluctuation lowered, lasting AL +PL
only 5 sec. (NN = 6sec.), due to microcirculatory inactivation ,
provoked by the hormon, under pathological condition.

3)Natriuretic
Atrial Peptides (A and B) Evaluation: in order to assess NAD type A,
i.e. NAD synthesized by heart, doctor applies “intense”
digital pressure on cutameous heart projection area and simultaneously
evaluates kidney behaviour, namely congestion of the kidney. In healthy,starting 5 sec. from the beginning of pressure application on precordium,
kidney transverse diameter augments of about 3 cm. and its fluctuations
show the maximal intensity, 1,5 cm., i.e. Highest Spikes, with AL + PL (duration)
lasting 8 sec. On
the contrary, in presence of heart coronary disease, excluding
early stage, kidney congestion appears to be clearly smaller than
normal value, in direct correlation with the seriousness of
underlying disorder. In fact, in case of severe myocardial ischaemia,
kidney size does not change, because NAD level is really increased, but receptors
sensitivity is lowered, due toreceptorsdown-regulation. The
assessement ofNAD type B
(B = brain), synthesized also by cardiac ventricles, doctors
applies intense hand or digital pressure on cutaneous projection area of
the parietal lobe, right and/or left, because other cerebral
convolutions cannot synthesize NAD type B,and simoltaneously estimates- See above – kidney behaviour: the response is normal
in patient with coronary heart disease, whereas in brain
vascular disorder as well as in other cerebral pathologies,
response appears to be smaller than normalor completely absent, in correlation with disease seriousness.
In conclusion, my findingsallow
to state that in both cerebral and myocardial ischaemia, due to renal
receptorsdown-regulation, although NAD secretion is really
intense, augmentationof
the kidneys size, secondary to congestion, is absent or statistically
not significant.

4)Renal Function Evaluation by load of
water. It is an original bed-side evaluation of renal function,
related in a satisfactory way to RPF and GFR. At first, in a indivual in
supine position and psycho-physically relaxed,doctor assesses renal
diameters, evaluated as minimal degree, renogram, i.e the
chaotic-deterministic fluctuations of kidney besides period, duration
and intensity of ureteral peristaltic wave.In
healthy, following data are observed: 6 cm. x 12 cm.,Phase C (kidney congestion) duration 6 sec., oscillation
intensity varying between 0,5 cm. and 1,5 cm. in a chaotic-deterministic
manner, period fluctuating between 9 sec. and 12 sec. In addition, the
peristaltic wave period at base-line is 18 sec., intensity < 1 cm.
and, finally, duration of urether dilation is 3 sec. exactly.Soon
thereafter, subject is administered 250 cc. water and then, after a
latency time of 3 minute, the degree of above- mentioned parameters, are
evaluated for a second time. “Minimal” kidney diameters increases
(> 6 cm. and respectively > 12 cm.), renogram appears to be of
“vagal” type,i.e. Phase C is clearly augmented with 7-8 sec.
durationand all
fluctuations are identical, as far as intensity and period are concerned.
In addition, ureteral peristaltic wave shows an incresed intensity (³
1 cm.) lasting for 6 sec. (doubled than that at base-line) and a period
decreased to 12 sec. exactly.Actually,
the degree of the numerous renal parameters are related in a
satisfactory manner to RPF, while ureteral parameters are correlated
with GFR.

5)
Uric
Acid Pool Expansion. In healthy, pinching(or digital pressure, applied on)bended auricular helix, between thumb and finger, provokes
gastric aspecific reflex after lt. of exact10 sec.On the
contrary, when acid uric pool expansion is present, for instance during renal
colic,above-mentionedstimulation causes the reflex after a shorter latency time
(e.g. < 7 sec.), in inverse correlation with the severity of
underlying disorder. Of interest, in case of articular or abarticular
gout, both digital and ungueal pressure on the diseased
“sinovium” induce gastric aspecific riflex and lt is in inverse
correlation with disease seriousness.Finally, of special interst is the sensitivizedassessement bymeans
of Ferrero-Marigo’smanoeuvre
(See earlier): even in previous episode of uric acid pool
expansion, in at momentonly apparently healty individual, i.e. apart from
actual acid uric blood level, doctor observes pathological values of the
reflex.

Velocimetry

(neologism,
indicating the clinical, original study of peristaltic waves)

Assessement
of the velocity of peristaltic wave

(evaluated
as time of conduction)

1)Esophagus. Physiologically, cutaneous pinchingat the level of sternal manubrium brings abouta peristaltic wave, which reaches cardias region after 5-6 sec.
along great stomach curvature. Doctor can observe this event with the
aid of auscultatory percussion of the stomach. On the contrary, in
esophageal pathology, independent from it origin, including thus hiatal
hernia, lt. or time of conduction araise to 7-8 sec. in directe
correlation with intensity of disorder.

2)Cholecyst-Choledochus.Cutaneous pinching at right of cholecyst projection area
originates a peristaltic wave in this viscera, wich is perceived at the
level of mean third of choledochus after 5 sec. precisely. In case of cholecystitis,
cholelithiasis, adenoma or tumour, conduction time increases to 8
sec.

4)Stomach-Duodenum.
Auscultatory percussion of the stomach and duodenum allows doctorto assess the time of conduction of a peristaltic wave,
originated as usually at cardias level, due to cutaneous pinching
immidiately under sternal xiphoid process, which reaches antral-pyloric
region in 5 sec. and duodenum (II duodenal segment) in 7 sec.